Powell Parks & Recreation Guide - Summer 2019

Medical Info/Special Notes

(Parent or Guardian if applicable)

PLEASE SIGN BELOW. SIGNATURE REQUIRED TO PARTICIPATE. RELEASE OF ALL CLAIMS AND PROMISE NOT TO SUE. As a participant in this and/or any other program of the City of Powell, I recognize and acknowledge that there are certain risks and I agree to assume all such risks including any damages resulting from physical injuries, death, loss of services or consortium, loss or damage to property, or any other loss which I may sustain as a result of participating in any and all activities connected with or associated with such programs. In consideration of the City of Powell accepting me or my child’s registration, and with intent to be legally bound, I hereby, for myself, my child, all heirs, executors, administrators and assigns, do hereby forever release, waive and relinquish all claims I have against its officers, agents, servants, employees, officials, facility providers and insurers from any and all liabilities, claims, demands, actions or causes of action resulting from physical injuries, including death, loss of services or consortium, loss or damage of property, or any other loss which I may have or my child may have, or which may accrue to me on account of my or my child’s participation in this and all other programs of the City of Powell. I/we have read and agree to the registration policies, including the right to use my/my child’s photograph or image with or without my/my child’s name, both single and in conjunction with other persons or objects for any or all purposes, including, but not limited to, private and public presentations, advertising, publicity and promotions relating thereto. Date Signature/Participant or Parent/Guardian (if participant is under age 18) READ CAREFULLY - BY SIGNING THIS YOU MAY GIVE UP IMPORTANT LEGAL RIGHTS.

Home Phone: Other Phone:

Please Print, Fill Out Completely & Sign Below

Zip Code: Email:

Recreation Program Enrollment Form

Village Green Municipal Building • 47 Hall Street • Powell, Ohio 43065-8357 • Phone: 614.885.5380 • Fax: 614.885.5339

Program # Program Name Participant Name Birthdate Sex Program Fee



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